Patients benefit from proactive, team-based approach to care


After attending the first learning workshop of the APCC Program, representatives from Daisy Hill Medical Surgery were enthusiastic about employing a practice nurse. By embracing this new role at the practice, the entire team were able to provide better care to their patients, particularly in improving access and providing a proactive and patient-centred approach to chronic disease care.

Location: Daisy Hill Medical Surgery, Daisy Hill, Qld.

Practice: 2 nurses, 6 reception staff, a practice manager and 8 GPs (6.0 FTE).

Patients: 8,000 active patients on the database.

Aim: To improve patient outcomes, improve access and to be able to effectively measure their improvements.


When Daisy Hill Medical Surgery (Daisy Hill) were offered the opportunity to join the APCC Program, as a team they felt they could use a challenge, and agreed to participate. The feeling amongst the team was that they were “doing OK, but there is always room for improvement.” The practice team agreed that their biggest focus was to improve access to care. This became evident when staff at Daisy Hill noticed some patients were unable to see their GP for up to three weeks, and some of the GPs felt it would be necessary to close their books completely. The opportunity to improve diabetes and heart disease care was also welcome. Some of the staff also saw
it as a welcome opportunity to discuss employing a practice nurse.


The first step they took towards improving their efficiency was to employ a practice nurse (PN). The value of a practice nurse had become evident to the lead GP and practice manager, who had both attended the APCC workshops. They developed a ‘job description’, to highlight the value of employing a PN.

This was then presented back to the practice team, which helped the other staff understand the role and tasks the PN would undertake.

The practice nurse quickly demonstrated her skills and helped to save GPs’ time on standard procedures, which allowed them more time to focus on providing the best care for their patients. As part of her role, the PN updated the patient database to clarify active patients and ensured patients with a chronic disease were being correctly identified in the clinical software. The database updating included searching for patients through the clinical software who were on diabetic drugs but not coded as a patient with diabetes, this was also done for patients with a heart disease.

To improve patient access, the practice manager blocked out appointments each day, which were then reserved for ‘on the day’ bookings only. One appointment each hour is blocked out, as well as the 8.30am – 8.45am appointment time for emergency issues, repeat prescriptions and referrals.

The physical aspects of the practice also changed dramatically. As a result of appropriate triaging through the PN, the practice has had three ‘face lifts’ to date. There is now a dedicated electrocardiography (ECG) room, an asthma/isolation room, a chronic disease room and a procedure area.

The practice nurse helped the GPs with correct coding in the clinical software so that all reports and databases would be accurate. Other aspects of her role included triaging patients, recalls and  implementing better reminder systems, sterilising, immunisations and wound dressings.

The PN spends time educating patients with a chronic disease on their illness, diet, exercise and lifestyle, which is followed up by the GPs, who are also using the chronic disease item numbers more efficiently


Through their involvement in the APCC Program, the practice team has been able to make a number of changes to help them work more efficiently and proactively. Some of their outomes include:

  • Daisy Hill MS is now recognised as a leading practice throughout the state and is often approached by experienced GPs looking for employment opportunities.
  • Improved access to care as a result of better booking strategies, inclusion of a booking slot for the nurse and well organised triage managed by the practice nurse.
  • Employing a PN took a lot of pressure away from the GPs and allowed the entire practice team to focus on proactively caring for their patients.
  • The practice income has increased through appropriate use of chronic care items.
  • GPs are now more time efficient.
  • The team is less stressed and have built a strong team approach to all aspects of the practice.
  • Learning how to use the data they collect and store within their databases allows the team to effectively measure their improvements, gives them feedback on their performance and motivates them to continue making improvements. They can now refer to figures and stats extracted from the clinical software to confirm and endorse their performance.
  • The opportunity for staff to present at the Collaboratives workshops has opened doors to presenting at other (non-APCC related) events including practice nurse groups, practice manager groups, men’s health, women’s health and refugee health community events.
  • Staff and clinical meetings are now more focussed and occur on a regular basis, with various tactics and skills discussed and a desire to find new tools for efficiency.
  • Daisy Hill MS won the Local Business Achievers Award 2005, in the ‘professional’ category (comprising of solicitors, accountants, medical services, etc) after being nominated by their patients and undergoing a ‘mystery shopper’ assessment.
  • Lead GP Dr Nick Stephens won a ‘Highly Commended – Recognising exceptional support for women with breast cancer’, award.
  • Patient feedback has been positive, with most patients commending the practice for introducing them to a practice nurse, whom they can contact for medical enquiries if needed.


Staff at Daisy Hill Medical Surgery participated in the APCC Program in the hopes of improving access to the surgery and to encourage the entire team to engage in the employment of a practice nurse. With a practice nurse employed, many systems were improved, including triaging, data cleansing and patient education, which all contributed to improving their patient access. As a result of the practice nurse taking on many daily procedures, GPs have more time for chronic disease and patient centred care, which over time has evolved into a proactive system for treating patients with a chronic disease.

“We were in the first wave of the Collaboratives and will confess that our first aim was to see what it was all about and if change really could happen… We
became convinced after seeing what other practices were achieving and felt it was time to make a change for the better.”
– Dr Nick Stephens

The Australian Primary Care Collaboratives Program is funded by the Australian Government Department of Health and delivered by the Improvement Foundation.


February 26, 2014

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